Compulsive skin picking: It’s not a ‘bad habit’ – it’s a disorder that took over my life

Mental health problems are often isolating, no matter how common they are.

i has spoken to two women about their experience of compulsive skin picking, a disorder less commonly known by its medical name: dermatillomania. Skin picking, compulsive hair pulling and nail biting to the point of causing wounds or serious harm are all body focused repetitive behaviours which, if left untreated, can become extremely debilitating.

The TLC Foundation estimates 75 per cent of those affected by dermatillomania are female.

Liz Atkin, 40, is a visual artist living in south London whose experience of skin picking began at the age of five. This compulsion dominated her life until ten years ago, when she began exploring how her interest in art could be harnessed and used as a device for controlling her condition.

Enormous guilt and shame

Liz Atkin

“For about 25 years I hid the condition from everybody in my life.

“The condition in my case was pretty chronic. I would pick most of my body and my face. Under my clothes most of the time there were wounds, marks and scars. I couldn’t last a couple of seconds without my fingers repeatedly either picking at themselves or touching my face.

A culture of perfect skin

“The guilt and shame of this disorder is enormous and those of us who live with it have probably spent decades hiding it. My whole wardrobe was geared around covering up parts of my body. I didn’t own a t-shirt for 10 years because my arms were a mess. I didn’t go swimming.

Those suffering from a more extreme version of dermatillomania can permanently disfigure their skin

“We live in a culture where perfect skin is everywhere in media and photographs. If people see marks on your body they often think ‘what is it?’”

Alternative therapies

Liz Atkin’s artwork

Ms Atkin eventually turned to photography and drawing to manage her disorder. “I have to be mindful and find ways of refocusing my hands because it’s the first thing my body does if I’m sedentary, tired, bored, angry, if I have a feeling of anxiety – it’s so automatic.” she explains. “Medication didn’t work for me and therapy didn’t stop it.

“Instead of picking, I would take a photograph. The energy of taking a photograph really helped me keep my fingers busy in a different way. A lot of the artworks I would create are about the skin. Instead of thinking this was something I should hide, I started making artwork on the parts of my body that were so damaged; my chest, back, arms and face.”

Another way she manages the urge to pick at her skin is by creating charcoal drawings on free newspapers handed out during her commute. She then gives her drawings away for free with postcards explaining that she has a mental health disorder.

The benefits of her drawings are twofold: they occupy her hands during a tedious part of the day and they raise awareness of a lesser-known condition. Ms Atkin has given away 10,000 drawings to strangers in the last year.

She now acts as an advocate for people with body focused repetitive behaviours and travels the world to deliver talks about turning a compulsive illness into the act of compulsively drawing.

Liz Atkin gives away one of her drawings

Constantly at war with myself

Anna Priemaza is an author and practising family and immigration lawyer in Alberta, Canada. Her compulsive skin picking began when she was a teenager but she says she now finds it hard to remember a time when she did not struggle against the compulsion.

“I am constantly at war with myself,” she says. “Every part of my life is littered with tools and tricks to help me in that war. I have fidget toys in my purse and in the car and in every room of the house. I have cleansing wipes in my desk drawer. I have cognitive behavioural therapy skin picking logs in my filing cabinet.

Anna Priemaza

“There is that kind of embarrassment and guilt and shame associated with the fact that you are doing it to yourself”

Dr Fred Penzel

“I started speaking openly about my dermatillomania and other mental health problems around a year ago when my publishing deal was announced. My book, Kat and Meg Conquer the World, is a young adult novel about a girl with an anxiety disorder and a girl with attention deficit hyperactivity disorder (ADHD). I realised that I couldn’t send a book out into the world about two badass teen girls who are open about their own struggles when I wasn’t being open about mine.

“It is still terrifying to speak about in the legal world, though. As lawyers, our job revolves around using our brains, so I’m always nervous that if I’m open about my struggles, people will think I’m not suited for my job, which, of course, is rubbish.”

A disorder, not a habit

Dr Fred Penzel is executive director of Western Suffolk Psychological Services in New York, where he specialises in the treatment of obsessive compulsive disorder (OCD) and body-focused repetitive behaviours. He says one of the biggest misconceptions about this disorder is that it is just a “bad habit” that needs to be broken.

“It is not just simply a habit,” he stresses. “It becomes habitual through constant repetition but people really become debilitated by these things. The behaviours themselves are pretty similar, person to person, but these are very complex problems.”

This was reaffirmed when skin picking disorder was added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the US in 2013.

“When I found out that it was added to the DSM, I wept,” says Ms Priemaza. “I had spent so many years trying to stop my ‘bad habit’. I’ve hit myself and yelled at myself and put bandaids on my fingers and elastics on my wrists and cried in frustration again and again when nothing helped. To find out that it wasn’t just a bad habit, but something bigger than that, made me feel validated, relieved and understood.”

Sores, bleeding and scarring

Dr Anjali Mahto

Anjali Mahto, a medical and cosmetic consultant at the Cadogan Clinic in London, says dermatillomania is one of the less common conditions presented by patients in her clinics. It disproportionately affects women and typically begins during teenage years and early adulthood.

People with this condition often fall into one of two groups: those who already have a skin condition and those who do not. “You have the group who’ve got normal variations of their skin problems – people who generally have freckles, or moles, or acne spots – and they start picking at their skin.

“In the second group are people who do not have skin defects, but the person feels there is something on their skin they are trying to scratch.

“What they end up doing is picking their skin until the point where they get sores, bleeding and more importantly scarring, which is quite hard to treat.”

Associated with depression or anxiety

An example of Liz Atkin’s artwork

“It’s thought to really have a problem with an underlying mental health issue or psychiatric disorder, so usually it is associated with people who have depression, anxiety or OCD.

“People who tend to pick often aren’t even aware they are doing it. Sometimes they are picking during periods where they are stressed and they are anxious and can be completely unaware of the fact they are doing it. Once they have picked the skin, they feel better, relief or pleasure.”

Some people can be left with scratches, while others suffering from a more extreme version of it can permanently disfigure their skin.

“I’ve had one patient who contracted flesh-eating bacterias.”

Dr Fred Penzel

Dr Penzel says the causes of this condition are still under investigation by clinics such as his own and the TLC Foundation, a nonprofit research centre for body focused repetitive behaviours and people who live with them. “There may be some hormonal or biological input into the problem,” he says.

The stigma inextricably linked to the condition can make talking about it feel like an insurmountable task for his patients. “They can be very embarrassed about it and they are aware to some degree about what they are doing. They often wear long sleeves or clothes to cover it up and hide it.”

But this disorder is more prevalent than people realise, he said.

“People who do this are not alone. This is not a rare and isolated thing and people should take it seriously. There are people who don’t look for employment and who don’t socialise because of this problem.”

He said people can also contract serious infections from skin picking. “I’ve had one patient who contracted flesh-eating bacterias. Another picked a hole through one of her nostrils.”

Treatment really works

Dr Mahto said habit reversal training is a commonly used treatment by clinical psychologists and psychiatrists as breaking the compulsion can be difficult without this psychological help. Oral medications can also be used as part of a treatment programme.

Oral medications can also be used as part of a treatment programme.“We often tend to use SSRIs such as Escitalopram, Fluoxetine and Sertraline. They can be very helpful as well.”

“The best treatment we have found so far is called comprehensive behavioural therapy,” says Dr Penzel. “That is where we try to identify all the various inputs: environmental, cognitive, biological, sensory. Once we’ve identified them we modify or control them to reduce the connection they have to the pulling and picking and biting.”

Patients at his clinic have also enjoyed some success with over the counter treatments and vitamins. These include an amino acid called NAC and inositol, a b-vitamin, which he has been using in his clinic for 21 years. “We’ve found that in many cases it really does stop the behaviour. Not for everyone, but for some people. In some it weakens the behaviour, in others it removes it completely.”

Crucially, he urges anyone experiencing body focused repetitive behaviours to seek help from a doctor or therapist even if their attempts to manage it have proved futile in the past.

“Treatment really works for this,” he adds. “It really helps.”

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